The Oxford Science Lecture Series

PROFESSOR WENDY SAVAGE

Gynaecologist, Bart's and London University

"Are there limits to reproductive choice?"

Thursday 5th March 1998

On Thursday 5th March 1998 a lecture in the Oxford Science Lecture Series was given by Professor Wendy Savage of Bart's and London University. Professor Savage began training and practising in obstetrics and gynaecology over 30 years ago, and has held a position as lecturer and honorary consultant in the London Hospital Medical College since 1977. She thus possesses an enormous wealth of experience in this field; but she also brings to her practice the added value of empathy with the patient, and a capacity to view each individual case from the perspective of the patient. She holds a firm belief in patient involvement in decisions such as the location of a delivery, whether natural delivery should be pursued in the case of a breech presentation, or whether a Caesarian section should be carried out only in the last resort. The exercise of maternal control over choices in matters pertaining to a child's birth has been found to strengthen the mother-baby bond, and can therefore be a key factor in the launching of a new human being into life.

The lecture centred around this theme of 'choice and control', whether at the level of governments and organizations in planning the size of a population, legislating on abortion, and the ethics involved in infertility (including surrogacy), or at the personal level regarding obstetric consultation and neonatal care, and aspects of delivery. In discussing these topics Professor Savage did not offer hard and fast solutions, but rather led us through the broad spectra of choice, dwelling on alternatives and thus offering a taste of the dilemmas which many people collectively and individually face.

Population statistics are depressing; projected statistics are downright worrying. If a government's ability to provide a basic standard of living for its citizens is stretched beyond its limits by a too rapid growth in population, does it have the right to enforce control over that growth?

Refusal to accept the legality of abortions has not infrequently forced desperate women to seek back-street assistance, causing unacceptably high mortality rates among women. The legalization of abortions should (but does not yet, universally) result in a more dignified outcome for the one who is designated by Nature to carry the can.

At the other end of the scale, various means of assisted reproduction are now being employed in cases of infertility. But such methods are expensive, and it is not clear what criteria should govern the selection of patients. The threat of 'semen for sale on the Internet' may be even more dire than the back-street 'abortion clinic' and has no visible control at all. Then, in the case of surrogacy, how is the situation to be resolved if the surrogate mother decides not to part with the child she has carried to term? Advancing technology also enables the consultant to learn the sex of a foetus. But if (as in certain ethnic societies) one sex is heavily preferred over the other, should that knowledge be withheld to avoid the risk of an illicit termination?

At the individual level, the pregnant woman is likely to seek professional advice at some stage more for reassurance than for treatment, since pregnancy is not an illness. But the home is less and less regarded as the natural focus for procreation itself: whereas 33% of all deliveries occured at home in 1958, that figure had fallen to 10% in only 12 years. If a first-time mother feels pressured to follow the rules of thumb of her antenatal clinic she may become sufficiently uncomfortable with the situation that she loses confidence in the professionals; if complications develop, any risks may thereby be aggravated. And should there be signs of complications (such as a breech presentation or a multiple birth) in which the risks are raised but are not necessarily threatening, it is all the more important to handle the individuality of the case sensitively, rather than categorize its relevance as a statistic. But if any patient declines her doctor's advice, how should the doctor react in the situation?

As Professor Savage pointed out frequently during her lecture, the price of choice is responsibility. And responsibility is a vital ingredient for the well-being of any society.

Dr Elizabeth Griffin.